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OSHA:Infection Control -The Pandemic Pandemonium

Lynn E. Lawrence, CMSgt(ret), USAF

MSOL, CPOT, ABOC, COA, OSC

https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html

Deploying Medical People

• Medical personnel moved

• Military medical people used

• Expect changes to the way medical personnel are employed in the future

What is Infection Control

5.d. Topics for initial, periodic, and as-needed education and training should include:

• Federal, state, and local education and training requirements

• Modes of infectious disease transmission and implementation of standard and transmission-based precautions • Hand hygiene

• Sharps injury prevention

• Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) for healthcare personnel

• Healthcare personnel screening for selected infectious diseases before job placement and periodically thereafter

• How to access occupational health services, when needed, and expectations for reporting exposures

https://www.cdc.gov/infectioncontrol/guidelines/index.html

What is a Pandemic

A pandemic (from Greek πᾶν, pan, 'all' and δῆμος, demos, 'people') is an epidemic of disease that has spread across a large region, for instance multiple continents, or worldwide. A widespread endemic disease with a stable number of infected people is not a pandemic. Further, flu pandemics generally exclude recurrences of seasonal flu.

What is a virus?

A virus is a small infectious agent that replicates only inside the living cells of an organism. Viruses can infect all types of life forms, from animals and plants to microorganisms, including bacteria and archaea

https://www.cdc.gov/coronavirus/2019-ncov/prepare/cleaning-disinfection.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcommunity%2Fhome%2Fcleaning-disinfection.html

Differences continued

DNA examples

• Adenoviruses

• Herpes viruses

• Pox-viruses

• Parovo-viruses

• Hepadna-viruses

RNA examples

• Reoviruses

• Picornoviruses

• Toga viruses

• Orthomyxoviruses

• Retroviruses

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Viruses Continued

• What are the Differences Between DNA and RNA Viruses?

• DNA viruses have DNA in their genome while RNA viruses have RNA in their genome. Unlike RNA viruses, DNA viruses pass their DNA into the nucleus of the host cell and not into the cytoplasm of the host cell. But RNA virus is first adsorbed to the host cell surface, fuses with the endosome membrane and releases the nucleocapsid into the cytoplasm. Hence, these are the key differences between DNA and RNA viruses

https://www.differencebetween.com/differences-between-dna-and-vs-rna-viruses/

Anti-Viral Medications

• In order to replicate, an RNA virus needs to make more copies of its RNA genome. This means antiviral drugs which block the copying of RNA genomes can potentially help treat COVID-19 patients. These drugs are known as RNA-polymerase inhibitors.

• Favilavir is an RNA polymerase inhibitor drug scientists are currently trialling against coronavirus.

• Another successful antiviral drug strategy is to use non-functional “analogues”, or inauthentic copies of the basic building blocks of the viral RNA genome. The presence of these analogues in the viral genome blocks the viral polymerase, meaning the virus cannot make another copy of its RNA. Acyclovir, ribavirin and azidothymidine (AZT) are examples of these drugs.

Anti-malarial drugs

Chloroquine, a well-known anti-malarial drug, has also gained attention. One study tested ittogether with a broad-spectrum antibiotic azithromycin. While some COVID-19 patients in this small study recovered, other patients died (despite chloroquine treatment), and some patients ceased treatment for a variety of reasons –including the severity of their symptoms.

Plaquenil was one of the drugs used in some of the cases

General Corona Information 12 Mar 20

Updated March 12, 2020, 12:30 p.m. PT (3:30 p.m. ET). The following sections have been updated in the past 24 hours: Latest statistics, Background, Questions you should ask to identify patients with possible exposure to SARS-CoV-2

www.aao.org/clinical-education

What is COVID-19

Coronaviruses are a large family of viruses that are common in humans and many different species of animals, including camels, cattle, cats, and bats. Rarely, animal coronaviruses can infect people and then spread between people, such as with MERS-CoV and SARS-CoV.The virus that causes COVID-19 is spreading from person-to-person in China and some limited person-to-person transmission has been reported in countries outside China, including the United States. However, respiratory illnesses like seasonal influenza, are currently widespread in many US communities.

Definitions Used in this Guidance

• Symptoms compatible with COVID-19, for the purpose of these recommendations, include subjective or measured fever, cough, or difficulty breathing.

• Self-observation means people should remain alert for subjective fever, cough, or difficulty breathing. If they feel feverish or develop cough or difficulty breathing during the self-observation period, they should take their temperature, self-isolate, limit contact with others, and seek advice by telephone from a healthcare provider or their local health department to determine whether medical evaluation is needed.

• Self-monitoring means people should monitor themselves for fever by taking their temperatures twice a day and remain alert for cough or difficulty breathing. If they feel feverish or develop measured fever, cough, or difficulty breathing during the self-monitoring period, they should self-isolate, limit contact with others, and seek advice by telephone from a healthcare provider or their local health department to determine whether medical evaluation is needed.

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Self-monitoringwith delegated supervision

means, for certain occupational groups (e.g., some healthcare or laboratory personnel, airline crew members), self-monitoring with oversight by the appropriate occupational health or infection control program in coordination with the health department of jurisdiction. The occupational health or infection control personnel for the employing organization should establish points of contact between the organization, the self-monitoring personnel, and the local or state health departments with jurisdiction for the location where personnel will be during the self-monitoring period. This communication should result in agreement on a plan for medical evaluation of personnel who develop fever, cough, or difficulty breathing during the self-monitoring period. The plan should include instructions for notifying occupational health and the local public health authority, and transportation arrangements to a pre-designated hospital, if medically necessary, with advance notice if fever, cough, or difficulty breathing occur. The supervising organization should remain in contact with personnel through the self-monitoring period to oversee self-monitoring activities.

Self-monitoring with public health supervision

means public health authorities assume the responsibility for oversight of self-monitoring for certain groups of people. The ability of jurisdictions to initiate or provide continued oversight will depend on other competing priorities (e.g., contact tracing, implementation of community mitigation strategies). Depending on local priorities, CDC recommends that health departments consider establishing initial communication with these people, provide a plan for self-monitoring and clear instructions for notifying the health department before the person seeks health care if they develop fever, cough, or difficulty breathing. As resources allow, health authorities may also check in intermittently with these people over the course of the self-monitoring period. If travelers for whom public health supervision is recommended are identified at a US port of entry, CDC will notify state and territorial health departments with jurisdiction for the travelers’ final destinations

Definitions Cont…

• Active monitoring means that the state or local public health authority assumes responsibility for establishing regular communication with potentially exposed people to assess for the presence of fever, cough, or difficulty breathing. For people with high-risk exposures, CDC recommends this communication occurs at least once each day. The mode of communication can be determined by the state or local public health authority and may include telephone calls or any electronic or internet-based means of communication.

• Close contact is defined as:

a) being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of time; close contact can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room with a COVID-19 case

– or –

b) having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on)

Public Health Orders

are legally enforceable directives issued under the authority of a relevant federal, state, or local entity that, when applied to a person or group, may place restrictions on the activities undertaken by that person or group, potentially including movement restrictions or a requirement for monitoring by a public health authority, for the purposes of protecting the public’s health. Federal, state, or local public health orders may be issued to enforce isolation, quarantine or conditional release. The list of quarantinable communicable diseases for which federal public health orders are authorized is defined by Executive Order and includes “severe acute respiratory syndromes.” COVID-19 meets the definition for “severe acute respiratory syndromes” as set forth in Executive Order 13295, as amended by Executive Order 13375 and 13674, and, therefore, is a federally quarantinable communicable disease.

Definition Cont…

• Isolation means the separation of a person or group of people known or reasonably believed to be infected with a communicable disease and potentially infectious from those who are not infected to prevent spread of the communicable disease. Isolation for public health purposes may be voluntary or compelled by federal, state, or local public health order.

• Quarantine in general means the separation of a person or group of people reasonably believed to have been exposed to a communicable disease but not yet symptomatic, from others who have not been so exposed, to prevent the possible spread of the communicable disease.

Conditional release

defines a set of legally enforceable conditions under which a person may be released from more stringent public health movement restrictions, such as quarantine in a secure facility. These conditions may include public health supervision through in-person visits by a health official or designee, telephone, or any electronic or internet-based means of communication as determined by the CDC Director or state or local health authority. A conditional release order may also place limits on travel or require restriction of a person’s movement outside their home.

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Controlled travel

involves exclusion from long-distance commercial conveyances (e.g., aircraft, ship, train, bus). For people subject to active monitoring, any long-distance travel should be coordinated with public health authorities to ensure uninterrupted monitoring. Air travel is not allowed by commercial flight but may occur via approved noncommercial air transport. CDC may use public health orders or federal public health travel restrictions to enforce controlled travel. CDC also has the authority to issue travel permits to define the conditions of interstate travel within the United States for people under certain public health orders or if other conditions are met.

Definition Cont…

• Congregate settings are crowded public places where close contact with others may occur, such as shopping centers, movie theaters, stadiums.

• Social distancing means remaining out of congregate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible.

Workplace Cautions

To prevent stigma and discrimination in the workplace, use only the guidance described below to determine risk of COVID-19. Do not make determinations of risk based on race or country of origin and be sure to maintain confidentiality of people with confirmed COVID-19. There is much more to learn about the transmissibility, severity, and other features of COVID-19 and investigations are ongoing. Updates are available on CDC’s COVID-19 web page

HR Companies are helpful with guidance

Recommended strategies for employers to use now:

• Actively encourage sick employees to stay home: • Employees who have symptoms of acute respiratory

illness are recommended to stay home and not come to work until they are free of fever (100.4° F [38.0° C] or greater using an oral thermometer), signs of a fever, and any other symptoms for at least 24 hours, without the use of fever-reducing or other symptom-altering medicines (e.g. cough suppressants). Employees should notify their supervisor and stay home if they are sick.

• Ensure that your sick leave policies are flexible and consistent with public health guidance and that employees are aware of these policies.

• What happens when people are told to stay home, what are you telling your employees?

Cont…

• Talk with companies that provide your business with contract or temporary employees about the importance of sick employees staying home and encourage them to develop non-punitive leave policies.

• Do not require a healthcare provider’s note for employees who are sick with acute respiratory illness to validate their illness or to return to work, as healthcare provider offices and medical facilities may be extremely busy and not able to provide such documentation in a timely way.

• Employers should maintain flexible policies that permit employees to stay home to care for a sick family member. Employers should be aware that more employees may need to stay at home to care for sick children or other sick family members than is usual.

.

Separate sick employees:

CDC recommends that employees who appear to have acute respiratory illness symptoms (i.e. cough, shortness of breath) upon arrival to work or become sick during the day should be separated from other employees and be sent home immediately. Sick employees should cover their noses and mouths with a tissue when coughing or sneezing (or an elbow or shoulder if no tissue is available).

Pay attention to sick providers and employees!!!

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Continued…

• Emphasize staying home when sick, respiratory etiquette and hand hygiene by all employees: Place posters that encourage staying home when sick, cough and sneeze etiquette, and hand hygiene at the entrance to your workplace and in other workplace areas where they are likely to be seen.

• Provide tissues and no-touch disposal receptacles for use by employees.

• Instruct employees to clean their hands often with an alcohol-based hand sanitizer that contains at least 60-95% alcohol or wash their hands with soap and water for at least 20 seconds. Soap and water should be used preferentially if hands are visibly dirty.

• Provide soap and water and alcohol-based hand rubs in the workplace. Ensure that adequate supplies are maintained. Place hand rubs in multiple locations or in conference rooms to encourage hand hygiene.

• Visit the coughing and sneezing etiquette and clean hands webpage for more information.

https://www.cdc.gov/healthywater/hygiene/etiquette/coughing_sneezing.html

https://www.cdc.gov/handwashing/index.html

Perform routine

environmental cleaning:

• Routinely clean all frequently touched surfaces in the workplace, such as workstations, countertops, and doorknobs. Use the cleaning/disinfection agents that are usually used in these areas and follow the directions on the label.

• No additional disinfection beyond routine cleaning is recommended at this time.

• Provide disposable wipes so that commonly used surfaces (for example, doorknobs, keyboards, remote controls, desks) can be wiped down by employees before each use.

• Prevent frames from being put back upon the frame board

Eyes and the Corona Virus

KGBT-TV As COVID-19 spreads across the U.S., health officials are urging you to not only wash your hands but to avoid touching your face. "I think it's very important that we get educated as a community and we come together, and we don't act inappropriately," said Eder Hernandez, Valley Med Urgent Care Chief Physician Assistant. Physician Assistant Hernandez said one change is to avoid rubbing your eyes and touching your face. "Surprisingly there is some ties between corona-virus and the eyes," If you touch your tears, there could be a high risk of infection in the eye.

Advise employees before traveling to take certain steps:

• Check the CDC’s Traveler’s Health Notices for the latest guidance and recommendations for each country to which you will travel. Specific travel information for travelers going to and returning from China, and information for aircrew, can be found at on the CDC website.

• Advise employees to check themselves for symptoms of acute respiratory illness before starting travel and notify their supervisor and stay home if they are sick.

• Ensure employees who become sick while traveling or on temporary assignment understand that they should notify their supervisor and should promptly call a healthcare provider for advice if needed.

• If outside the United States, sick employees should follow your company’s policy for obtaining medical care or contact a healthcare provider or overseas medical assistance company to assist them with finding an appropriate healthcare provider in that country. A U.S. consular officer can help locate healthcare services. However, U.S. embassies, consulates, and military facilities do not have the legal authority, capability, and resources to evacuate or give medicines, vaccines, or medical care to private U.S. citizens overseas.

Sick Family Members

• Additional Measures in Response to Currently Occurring Sporadic Importations of the COVID-19: Employees who are well but who have a sick family member at home with COVID-19 should notify their supervisor and refer to CDC guidance for how to conduct a risk assessment of their potential exposure.

• If an employee is confirmed to have COVID-19, employers should inform fellow employees of their possible exposure to COVID-19 in the workplace but maintain confidentiality as required by the Americans with Disabilities Act (ADA). Employees exposed to a co-worker with confirmed COVID-19 should refer to CDC guidance for how to conduct a risk assessment of their potential exposure.

How is the Corona Virus

Spread? • Person-to-person spread

• The virus is thought to spread mainly from person-to-person.

• Between people who are in close contact with one another (within about 6 feet).

• Through respiratory droplets produced when an infected person coughs or sneezes.

• These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.

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Clinical Presentation

Among reports that describe the clinical presentation of patients with confirmed COVID-19, most are limited to hospitalized patients with pneumonia. The incubation period is estimated at 4 days (interquartile range: 2 to 7 days). [1] Some studies have estimated a wider range for the incubation period; data for human infection with other coronaviruses (e.g. MERS-CoV, SARS-CoV) suggest that the incubation period may range from 2-14 days. Frequently reported signs and symptoms of patients admitted to the hospital include fever (77–98%), cough (46%–82%), myalgia or fatigue (11–52%), and shortness of breath (3-31%) at illness onset. [2–5] Among 1,099 hospitalized COVID-19 patients, fever was present in 44% at hospital admission, and developed in 89% during hospitalization. [6] Other less commonly reported respiratory symptoms include sore throat, headache, cough with sputum production and/or hemoptysis.

Possible Risk Factors

Patients with a mild clinical presentation may not initially require hospitalization. However, clinical signs and symptoms may worsen with progression to lower respiratory tract disease in the second week of illness; all patients should be monitored closely. Possible risk factors for progressing to severe illness may include, but are not limited to, older age, and underlying chronic medical conditions such as lung disease, cancer, heart failure, cerebrovascular disease, renal disease, liver disease, diabetes, immunocompromising conditions, and pregnancy. (Staff members too!!!)

Clinical Presentation continued:

Some patients have experienced gastrointestinal symptoms such as diarrhea and nausea prior to developing fever and lower respiratory tract signs and symptoms. The fever course among patients with COVID-19 is not fully understood; it may be prolonged and intermittent. A limited number of reports describe identification of asymptomatic or subclinical infection on the basis of detection of SARS-CoV-2 RNA or live virus from throat swab specimens of contacts of confirmed patients. [7–8]

https://www.cdc.gov/coronavirus/2019-ncov/prepare/transmission.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fabout%2Ftransmission.html

Can the virus spread through non-sick people?

• People are thought to be most contagious when they are most symptomatic (the sickest).

• Some spread might be possible before people show symptoms; there have been reports of this occurring with this new coronavirus, but this is not thought to be the main way the virus spreads.

• Some of the sick are asymptomatic

Announcement

The Academy is sharing important ophthalmology-specific information related to the novel coronavirus, referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was previously known by the provisional name 2019-nCoV. The highly contagious virus can cause a severe respiratory disease known as COVID-19.

Continued

This next few slides are principally authored by James Chodosh, MD, MPH, and Gary N. Holland, MD. Dr. Chodosh is the David G. Cogan Professor of Ophthalmology at Harvard Medical School’s Department of Ophthalmology, a member of Harvard’s PhD program in virology and a world-recognized cornea and external disease expert. Dr. Holland is the Jack H. SkirballProfessor of Ocular Inflammatory Diseases, director of the Ocular Inflammatory Disease Center, and chief of the cornea/external disease and uveitis divisions at the Jules Stein Eye Institute, David Geffen School of Medicine at UCLA.

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What you need to know

1. Several reports suggest the virus can cause conjunctivitis and possibly be transmitted by aerosol contact with conjunctiva.

Continued…

2. Patients who present to ophthalmologists/Optometrist (ECP) for conjunctivitis who also have fever and respiratory symptoms including cough and shortness of breath, and who have recently traveled internationally, particularly to areas with known outbreaks (China, Iran, Italy, Japan, and South Korea), or with family members recently back from one of these countries, could represent cases of COVID-19.

Continued…

The Academy and federal officials recommend protection for the mouth, nose and eyes when caring for patients potentially infected with SARS-CoV-2.

Staff members that come in contact with patients, so everyone must practice good infection control

Continued…

The virus that causes COVID-19 is very likely susceptible to the same alcohol-and bleach-based disinfectants that ophthalmologists commonly use to disinfect ophthalmic instruments and office furniture. To prevent SARS-CoV-2 transmission, the same disinfection practices already used to prevent office-based spread of other viral pathogens are recommended before and after every patient encounter. Verify that you are doing what the CDC suggest!

Latest statistics• Global cases: 125,048

(updated March 12, 2020; source: WHO)• Total deaths: 4,613• Countries reporting cases:

117

• U.S. cases: 125,000 confirmed and presumptive positive cases (updated April 4, 2020; source: CDC)• Total deaths: 8,000• States reporting cases: 50

World Health Organization (WHO)

On March 11, COVID-19 was officially declared a pandemic by the World Health Organization. Countries with documented ongoing widespread or sustained community transmission include China, Iran, Italy, Japan, and South Korea. The 2 countries with the highest number of cases, China and South Korea, have shown consecutive multi-day declines in new cases.

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Current information on COVID-19

Currently, U.S. COVID-19 cases include imported cases in travelers, cases among close contacts of a known case and community-acquired cases where the source of the infection is unknown. Based on the Johns Hopkins University COVID-19 interactive map, the states with the highest number of confirmed cases are Washington (373), New York (216), California (179) and Massachusetts (95).

Background

The SARS-CoV-2 is an enveloped, single-stranded RNA virus that causes COVID-19. Although the virus appears not quite as likely to cause fatalities as the SARS coronavirus or MERS coronavirus, a significant number of global fatalities have already occurred. There have been numerous worldwide reports of infections, including in the United States.

Presentations

Patients typically present with respiratory illness, including fever, cough and shortness of breath; conjunctivitis has also been reported. Severe complications include pneumonia. Symptoms can appear as soon as 2 days or as long as 14 days after exposure.

Testing

• Who needs to be tested

• Refer to PCM for proper care

• Some testing results can be completed in minutes (Abbott Test within 14 minutes positive or negative)

Recent Study

A March 10 study in the Annals of Internal Medicine found that the mean incubation period for SARS-CoV-2 was 5 to 7 days. More than 97% of those who developed symptoms did so within 11.5 days of exposure, findings that further support current 14-day quarantine recommendations.

10 Things Doctors Do To Protect Themselves

They are on the frontlines—but are human, just like you, and no one wants to catch the coronavirus. Here's how the country's medical professionals stay healthy enough to fight it.

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1.Shop Cautiously

"For grocery shopping, wearing gloves or repeatedly sanitizing hands, and not touching the face, helps reduce germ contact," says Dr. Delia Weiss, an internist who practices medicine in Boynton Beach, Florida. "Wiping or spraying sanitizer on the grocery cart and check out counter, are also helpful. For grocery, gas and bank keypads, the equipment may be sprayed or wiped before touching."

2. Make Yourself a

“Contamination Zone”

"When I get home, I load all of my groceries onto a designated area of my kitchen. I'm treating everything from outside as if it is potentially contaminated with the virus," says Dr. Jessica Nouhavandi, the lead pharmacist, founder, and CEO of Honeybee Health. "I wipe down everything with a Lysol wipe (with fresh fruit and vegetables, where possible I wash them with soap and water) before putting the groceries away. Lastly, I wipe down the countertop where I put all of the grocery bags initially."

3. Take Off Your Shoes

"Before I leave the hospital, I change out of the hospital scrubs and shoes into street clothes and shoes," says Dr. Michelle Lee, a board-certified, Harvard-trained plastic surgeon in California. "After I get home, the first thing that I do is shower. No outside shoes are allowed in the house."

4. Get Smart With Take Out

"I have them leave it outside the door (I tip extra online), wait 10 minutes, then take it in and then wipe it down with a Clorox wipe (the bag and boxes)," says Dr. Yuna Rapoport, "I always plate it and don't use the included Tupperware."

5. Carry Paper Towels/Sanitizing Wipes Around

"When I go out of my apartment, I take a paper towel to open all the knobs/elevator buttons on my way out, and have another paper towel on my way in," says Dr. Rapoport. "When I get home I will first wash my hands, then Clorox wipe my keys/wallet/phone, then wash my hands again."

6. Keep Their Distance

"As it has been said avoid social interactions that are not needed. When seeing patients I keep my distance," says Dr. Lugo, "Personal hygiene is in overdrive."

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7. They live a balanced life

"Eat a lot of fruits and drink plenty of water," says Dr. Lugo, "Spend time in the open doors taking fresh air, observing the social distancing mandate." You should also make exercise a part of your routine.

8. They Shield Their Faces

"A face shield offers much better protection (then just a mask alone) while interacting with the patients, as there is a chance they might literally cough in your face," says Dr. Dimitar Marinov, MD, Ph.D. and Assist. Professor at the Department of Hygiene and Epidemiology, Medical University of Varna, Bulgaria. "It is important to protect the whole face, as the virus can also enter through the mucous membrane of the eye."

9. They Remain Calm

"Since stress can lower immune defenses, immune-boosting practices are important," says Dr. Weiss, "Immune system boosting includes relaxation, stress reduction, adequate rest and hydration, good nutrient intake, ventilation of home and workspace, as able, such as opening a window or door, so that germ exposure load can be reduced." "I try to stay well-rested," says Dr. Rafael Lugo.

10. They Work For You. You Stay Home for Them.

"Please give the national efforts an opportunity to work," says Negin Blattman, MD, a clinical assistant professor at the University of Arizona College of Medicine—Phoenix and an infectious disease specialist, of the self-quarantine effort. "If you are honest, 99% of what you are stepping out to do can wait. I show up every day for my patient. We, as the medical community, are asking that you please stay home for us."

Trials have begun

At this time, there is no vaccine to prevent infection, and no medication known to be effective in treatment. On March 5, Kaiser Permanente begun enrolling for mRNA coronavirus vaccine trials in the Washington State area. How the virus spreads

Current understanding about how COVID-19 spreads is based largely on what is known about other similar coronaviruses. The virus is believed to spread primarily via person-to-person through respiratory droplets produced when an infected person coughs or sneezes. It also could be spread if people touch an object or surface with virus present from an infected person, and then touch their mouth, nose or eyes. Viral RNA has also been found in stool samples from infected patients, raising the possibility of transmission through the fecal/oral route.

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Asymptomatic Patients:

Currently, federal officials are trying to determine if there is asymptomatic transmission. A Feb. 21 report in JAMA details a case of an asymptomatic carrier who possibly infected 5 family members despite having normal chest computed tomography (CT) findings.

Already impacting the ophthalmic community

In addition, Li Wenliang, MD, the whistleblower ophthalmologist who sounded the initial alarms on the coronavirus, said he was infected by an asymptomatic glaucoma patient. These reports, however, are preliminary.

Ophthalmic Community News

Two recent reports suggest the virus can cause conjunctivitis. Thus, it is possible that SARS-CoV-2 is transmitted by aerosol contact with the conjunctiva.

Conjunctivitis Studies• In a Journal of Medical Virology

study of 30 patients hospitalized for COVID-19 in China, 1 had conjunctivitis. That patient—and not the other 29—had SARS-CoV-2 in their ocular secretions. This suggests that SARS-CoV-2 can infect the conjunctiva and cause conjunctivitis, and virus particles are present in ocular secretions.

• In this larger study published in the New England Journal of Medicine, researchers documented "conjunctival congestion" in 9 of 1,099 patients (0.8%) with laboratory-confirmed COVID-19 from 30 hospitals across China.

Clinics and Emergency Rooms

While it appears conjunctivitis is an uncommon event as it relates to COVID-19, other forms of conjunctivitis are common. Affected patients frequently present to eye clinics or emergency departments. That increases the likelihood ophthalmologists (ECP) may be the first providers to evaluate patients possibly infected with COVID-19.

Continued… reports on masks effectiveness changed

Therefore, protecting your mouth, nose (e.g., an N-95 mask) and eyes(e.g., goggles or shield) is recommended when caring for patients potentially infected with COVID-19. In addition, slit-lamp breath shields (e.g., here) are helpful for protecting both health care workers and patients from respiratory illness.

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Questions you should ask to identify patients with possible exposure to SARS-CoV-2

• Does your patient have fever or respiratory symptoms?

• Has your patient or their family members traveled recently?

• Red flags include international travel to countries such as China, Iran, Italy, Japan and South Korea, and domestic travel to states with high numbers of infected patients (e.g., Washington, California, New York)

• The CDC is urging health care providers who encounter patients meeting these criteria to immediately notify both infection control personnel at your health care facility and your local or state health department for further investigation of COVID-19.

• Future pandemics: get ahead and start asking the questions about travel

Recommended protocols when scheduling or seeing patients

When phoning about visit reminders, ask to reschedule appointments for patients with nonurgent ophthalmic problems who have respiratory illness, fever or returned from a high-risk area within the past 2 weeks.

Before entering the waiting area

Patients who come to an appointment should be asked prior to entering the waiting room about respiratory illness and if they or a family member have traveled to a high-risk area in the past 14 days. If they answer yes to either question, they should be sent home and told to speak to their primary care physician.

Waiting rooms guidance!

• Keep the waiting room as empty as possible and reduce the visits of the most vulnerable patients.

• One of our greatest challenges in the entire medical field

Isolation area

Sick patients who possibly have COVID-19 with an urgent eye condition can be seen, but personal protective equipment should be worn by all who come in contact with the patient. The CDC's recommendations for personal protective equipment include gloves, gowns, respiratory protection and eye protection. Place a facemask on the patient and isolate them in an examination room with the door closed; use airborne infection isolation rooms (AIIR) if available.

We must improve in this area in our ophthalmic community

Exam rooms and instruments

Rooms and instruments should be thoroughly disinfected afterward based on current CDC recommendations specific to COVID-19. Slit lamps, including controls and accompanying breath shields, should be disinfected after every patient, particularly wherever they put their hands and face.

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Employers: Lessons Learned…

Re-look at your employee manuals

Older adults and people who have severe underlying chronic medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness.• Pregnancy is a high risk per OSHA/NIOSH

• Avoid eating or drinking in patient care areas!!!

https://www.cdc.gov/niosh/topics/repro/pregnancyJob.html https://www.cdc.gov/niosh/topics/repro/healthcare.html

Risk Factors Geographic (Travel associated) Exposures Exposures Identified Through Contact Investigation

High Travel from Hubei Province, China Living in the same household as, being an intimate partner of, or providing care in a nonhealthcare setting (such as a home) for a person with symptomatic laboratory-confirmed COVID-19 infection without using recommended precautions for home care and home isolation

Medium (assumes no exposures in the high-risk category)

Travel from mainland China outside Hubei Province or IranTravel from a country with widespread sustained transmission, other than China or IranTravel from a country with sustained community transmission

Close contact with a person with symptomatic laboratory-confirmed COVID-19. On an aircraft, being seated within 6 feet (two meters) of a traveler with symptomatic laboratory-confirmed COVID-19 infection; this distance correlates approximately with 2 seats in each direction. Living in the same household as, an intimate partner of, or caring for a person in a nonhealthcare setting (such as a home) to a person with symptomatic laboratory-confirmed COVID-19 infection while consistently using recommended precautions for home careand home isolation

Low (assumes no exposures in the high-risk category)

Travel from any other country Being in the same indoor environment (e.g., a classroom, a hospital waiting room) as a person with symptomatic laboratory-confirmed COVID-19 for a prolonged period of time but not meeting the definition of close contact

No identifiable risk Not applicable Interactions with a person with symptomatic laboratory-confirmed COVID-19 infection that do not meet any of the high-, medium- or low-risk conditions above, such as walking by the person or being briefly in the same room.

Risk Assessment

• Symptoms compatible with COVID-19, for the purpose of these recommendations, include subjective or measured fever, cough, or difficulty breathing.

• Self-observation means people should remain alert for subjective fever, cough, or difficulty breathing. If they feel feverish or develop cough or difficulty breathing during the self-observation period, they should take their temperature, self-isolate, limit contact with others, and seek advice by telephone from a healthcare provider or their local health department to determine whether medical evaluation is needed.

Risk Assessment Continued

Self-monitoring means people should monitor themselves for fever by taking their temperatures twice a day and remain alert for cough or difficulty breathing. If they feel feverish or develop measured fever, cough, or difficulty breathing during the self-monitoring period, they should self-isolate, limit contact with others, and seek advice by telephone from a healthcare provider or their local health department to determine whether medical evaluation is needed.

Self-monitoring with delegated supervision

means, for certain occupational groups (e.g., some healthcare or laboratory personnel, airline crew members), self-monitoring with oversight by the appropriate occupational health or infection control program in coordination with the health department of jurisdiction. The occupational health or infection control personnel for the employing organization should establish points of contact between the organization, the self-monitoring personnel, and the local or state health departments with jurisdiction for the location where personnel will be during the self-monitoring period. This communication should result in agreement on a plan for medical evaluation of personnel who develop fever, cough, or difficulty breathing during the self-monitoring period. The plan should include instructions for notifying occupational health and the local public health authority, and transportation arrangements to a pre-designated hospital, if medically necessary, with advance notice if fever, cough, or difficulty breathing occur. The supervising organization should remain in contact with personnel through the self-monitoring period to oversee self-monitoring activities.

Self-monitoring with public health supervision

means public health authorities assume the responsibility for oversight of self-monitoring for certain groups of people. The ability of jurisdictions to initiate or provide continued oversight will depend on other competing priorities (e.g., contact tracing, implementation of community mitigation strategies). Depending on local priorities, CDC recommends that health departments consider establishing initial communication with these people, provide a plan for self-monitoring and clear instructions for notifying the health department before the person seeks health care if they develop fever, cough, or difficulty breathing. As resources allow, health authorities may also check in intermittently with these people over the course of the self-monitoring period. If travelers for whom public health supervision is recommended are identified at a US port of entry, CDC will notify state and territorial health departments with jurisdiction for the travelers’ final destinations.

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Active monitoring

means that the state or local public health authority assumes responsibility for establishing regular communication with potentially exposed people to assess for the presence of fever, cough, or difficulty breathing. For people with high-risk exposures, CDC recommends this communication occurs at least once each day. The mode of communication can be determined by the state or local public health authority and may include telephone calls or any electronic or internet-based means of communication.

Public health orders

are legally enforceable directives issued under the authority of a relevant federal, state, or local entity that, when applied to a person or group, may place restrictions on the activities undertaken by that person or group, potentially including movement restrictions or a requirement for monitoring by a public health authority, for the purposes of protecting the public’s health. Federal, state, or local public health orders may be issued to enforce isolation, quarantine or conditional release. The list of quarantinable communicable diseases for which federal public health orders are authorized is defined by Executive Order and includes “severe acute respiratory syndromes.” COVID-19 meets the definition for “severe acute respiratory syndromes” as set forth in Executive Order 13295, as amended by Executive Order 13375 and 13674, and, therefore, is a federally quarantinable communicable disease.

Isolation and Quarantine

• Isolation means the separation of a person or group of people known or reasonably believed to be infected with a communicable disease and potentially infectious from those who are not infected to prevent spread of the communicable disease. Isolation for public health purposes may be voluntary or compelled by federal, state, or local public health order.

• Quarantine in general means the separation of a person or group of people reasonably believed to have been exposed to a communicable disease but not yet symptomatic, from others who have not been so exposed, to prevent the possible spread of the communicable disease

Continued

• Conditional release defines a set of legally enforceable conditions under which a person may be released from more stringent public health movement restrictions, such as quarantine in a secure facility. These conditions may include public health supervision through in-person visits by a health official or designee, telephone, or any electronic or internet-based means of communication as determined by the CDC Director or state or local health authority. A conditional release order may also place limits on travel or require restriction of a person’s movement outside their homes

• Congregate settings are crowded public places where close contact with others may occur, such as shopping centers, movie theaters, stadiums.

Exposure Risk Categories

• These categories are interim and subject to change.

• CDC has established the following exposure risk categories to help guide public health management of people following potential SARS-CoV-2 exposure in jurisdictions that are not experiencing sustained community transmission. These categories may not cover all potential exposure scenarios. They should not replace an individual assessment of risk for the purpose of clinical decision making or individualized public health management.

• All exposures apply to the 14 days prior to assessment.

• For country-level risk classifications, see Coronavirus Disease 2019 Information for Travel.

Key Concepts in This Guidance

• Limit how germs can enter the facility. Cancel elective procedures, use telemedicine when possible, limit points of entry and manage visitors, screen patients for respiratory symptoms, encourage patient respiratory hygiene using alternatives to facemasks (e.g., tissues to cover cough).

• Isolate symptomatic patients as soon as possible. Set up separate, well-ventilated triage areas, place patients with suspected or confirmed COVID-19 in private rooms with door closed and private bathroom (as possible), prioritize AIIRs for patients undergoing aerosol-generating procedures.

• Protect healthcare personnel. Emphasize hand hygiene, install barriers to limit contact with patients at triage, cohort COVID-19 patients, limit the numbers of staff providing their care, prioritize respirators and AIIRs for aerosol-generating procedures, implement PPE optimization strategies to extend supplies.

https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

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Definitions Cont…

• Controlled travel involves exclusion from long-distance commercial conveyances (e.g., aircraft, ship, train, bus). For people subject to active monitoring, any long-distance travel should be coordinated with public health authorities to ensure uninterrupted monitoring. Air travel is not allowed by commercial flight but may occur via approved noncommercial air transport. CDC may use public health orders or federal public health travel restrictions to enforce controlled travel. CDC also has the authority to issue travel permits to define the conditions of interstate travel within the United States for people under certain public health orders or if other conditions are met.

• Social distancing means remaining out of congregate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible.

Risk Level Management if Asymptomatic Management if Symptomatic1

High Quarantine (voluntary or under public health orders) in a location to be determined by public health authorities.No public activities.Daily active monitoring, if possible based on local prioritiesControlled travel

Immediate isolation with consideration of public health ordersPublic health assessment to determine the need for medical evaluation; if medical evaluation warranted, diagnostic testing should be guided by CDC’s PUI definition If medical evaluation is needed, it should occur with pre-notification to the receiving HCF and EMS, if EMS transport indicated, and with all recommended infection control precautions in place.Controlled travel: Air travel only via air medical transport. Local travel is only allowed by medical transport (e.g., ambulance) or private vehicle while symptomatic person is wearing a face mask.

Medium (assumes no exposures in the high-risk category)

Close contacts in this category: Recommendation to remain at home or in a comparable settingPractice social distancingActive monitoring as determined by local prioritiesRecommendation to postpone long-distance travel on commercial conveyances

Self-isolationPublic health assessment to determine the need for medical evaluation; if medical evaluation warranted, diagnostic testing should be guided by CDC’s PUI definition (Persons Under Investigation)If medical evaluation is needed, it should ideally occur with pre-notification to the receiving HCF and EMS, if EMS transport indicated, and with all recommended infection control precautions in place.Controlled travel: Air travel only via air medical transport. Local travel is only allowed by medical transport (e.g., ambulance) or private vehicle while symptomatic person is wearing a face mask.

Low (assumes no exposures in the high-risk category)

Travelers from mainland China (outside Hubei Province) or Iran Recommendation to remain at home or in a comparable settingPractice social distancingSelf-monitoring with public health supervision as determined by local prioritiesRecommendation to postpone additional long-distance travel on commercial conveyances after they reach their final destination

Self-isolation, social distancingPerson should seek health advice to determine if medical evaluation is needed. If sought, medical evaluation and care should be guided by clinical presentation; diagnostic testing for COVID-19 should be guided by CDC’s PUI definition.Travel on commercial conveyances should be postponed until no longer symptomatic.

No identifiable risk Travelers from country with sustained community transmission Practice social distancingSelf-observation

Recommendations

1. Minimize Chance for Exposures

2. Adhere to Standard and Transmission-Based

Precautions3. Patient Placement

4. Take Precautions When Performing Aerosol-

Generating Procedures (AGPs)

5. Collection of Diagnostic Respiratory Specimens

6. Manage Visitor Access and Movement Within the

Facility

7. Implement Engineering Controls

8. Monitor and Manage Ill and Exposed Healthcare

Personnel

9. Train and Educate Healthcare Personnel

10. Implement Environmental Infection

Control

11. Establish Reporting within and between

Healthcare Facilities and to Public Health

Authorities

12. Appendix: Additional Information about Airborne Infection Isolation Rooms,

Respirators and Facemasks

https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

Myths: Don’t Believe Everything You Hear

• Home remedies can cure or prevent the virus

• Reality: Garlic is good for you. So is water. And vitamin C. But despite what some corners of social media would have you believe, there's no evidence from the outbreak that eating garlic, sipping water every 15 minutes or taking vitamin C will protect people from the new coronavirus. Same goes for using essential oils, colloidal silver and steroids.

• Some posts have suggested that putting sesame oil on your body or spraying yourself with alcohol or chlorine will kill the virus. That's also false.

• There are some chemical disinfectants, including bleach, 75% ethanol, peracetic acid and chloroform, that may kill the virus on surfaces. But if the virus is already in your body, putting those substances on your skin or under your nose won't kill it -- and can actually be dangerous.

https://www.msn.com/en-us/health/medical/debunking-the-coronavirus-myths-and-misinformation/ar-BB10IxnP

Myths: Continued

• Everyone should wear a mask

• Reality: This one's a little trickier and varies from country to country.

• The CDC has said that Americans who are well do not need to wear face masks, while US Surgeon General Jerome Adams warned that masks could actually increase the risk of infection if they aren't worn properly.

• Given the shortage of masks in the US and the resulting price-gouging, US officials have warned the public not to hoard masks, particularly N95 respirators, so that they remain available to those most at risk. Those who should wear masks are people who already have the new coronavirus and could potentially infect others, those caring for an infected patient in close settings and health care workers.

https://www.msn.com/en-us/health/medical/debunking-the-coronavirus-myths-and-misinformation/ar-BB10IxnP

Myths: Continued

• Myth: Heat can kill the virus

• Reality: Hand dryers can't kill the virus, according to WHO. The organization also says that UV lamps shouldn't be used to sterilize hands or other areas of the body because the radiation can irritate skin.

• President Donald Trump has previously suggested that heat kills the virus and that because of this, the current outbreak will have dissipated by spring.

• But public health experts say there's no way to know this.

https://www.msn.com/en-us/health/medical/debunking-the-coronavirus-myths-and-misinformation/ar-BB10IxnP

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Myths: Continued

• Myth: Kids can't get the coronavirus

• Reality: Anyone of any age can get the new coronavirus, though older people and those with pre-existing medical conditions appear to be more vulnerable to serious infections.

• While most confirmed cases of the virus have occurred in adults, children have been infected too, according to the Centers for Disease Control and Prevention.

https://www.msn.com/en-us/health/medical/debunking-the-coronavirus-myths-and-misinformation/ar-BB10IxnP

Myth: Continued

• Myth: Black people don't get coronavirus

• Reality: Anyone can get coronavirus.

• Any person who comes into close contact with someone who is infected is at risk for contracting the virus, according to the CDC.

• Look no further than Africa, where the pandemic is gaining a foothold. So far, the virus hasn't spread in Africa as quickly as it has on some other continents. But numbers there are rising fast.

• Ten African nations have reported nearly 100 coronavirus cases. Egypt has been the worst hit with at least 59 cases -- more than half of all confirmed cases on the continent.

https://www.msn.com/en-us/health/medical/debunking-the-coronavirus-myths-and-misinformation/ar-BB10IxnP

Caution: Asymptomatic people can spread it!

These officials have emphasized that the virus is spread mainly by people who are already showing symptoms, such as fever, cough or difficulty breathing. If that's true, it's good news, since people who are obviously ill can be identified and isolated, making it easier to control an outbreak.

Infection Control

As healthcare workers, we must take full responsibility for our behavior. Our primary goal is to do no harm to anyone (patients or staff)

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What is the Bloodborne Pathogens Standard & Exposure Control Plan?

• Determines exposure risks

• Provides protection i.e., PPE

• Hep. B vaccines at no cost

• Ongoing training, testing and instruction

• Records of employees’ BBP training and medical records

• We in the ophthalmic community need to stop thinking we are so safe

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Exposure Determination

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What are “Universal Precautions”?

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“Universal Precautions”Treat every patient as if they are known to have

an infectious disease.

Take appropriate precautions to prevent the spread of that disease.

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Personal Protective Equipment (“PPE”)

• Located ( must be by location)

• Protects against airborne, droplets, contact pathogens

• Masks, gowns, gloves, shoe covers: one-time use.

• Dispose of in the red bag after use.

• (if you have goggles available) Goggles are available for splash protection or protection from laser light. Re-usable.

•Use personal protective equipment whenever there is a reasonablepossibility of exposure to infectious blood or body fluids or chemical fumes.

•Patients with compromised immune systems

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Personal Protective Equipment

• If a garment is penetrated by blood or other infectious material remove it immediately.

• Remove PPE before leaving your work area.

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Must Have

• You can get guards for both sides of the slit lamp

• PPE is a must for those with potential infections (patients and staff)

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Laser Protection Requirements

• We have a policy for staff working in laser hazard areas and they must follow all safety procedures.

• Must read safety requirements for:

• Co2 Laser

• YAG/SLT Lasers1/18/2021

Exposure Incidents

• What constitutes an “exposure incident”?

• Who do I tell?

• What happens after the exposure incident?

• Complete Incident form 1/18/2021

What to do if one of your patient’s identify as COVID-19 positive?

What is the Single MostImportant Thing We Can Do To Prevent The Spread of Disease?

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Handwashing

• Essential to reduce infections and maintain safety of patients.

• Foam in every room! Rub hands until dry (not for contact lens patients)

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Handwashing

• Wash your hands:• Before:

• reporting to work• leaving the office

• Before and after: • Gloving• Each patient • Touching body fluids, non-intact skin

or wound dressings• Eating or drinking

• After:• using the restroom• blowing or wiping the nose• touching a contaminated surface• After cleaning

• Whenever your hands become visibly soiled

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CDC Approved Wipes

• https://www.drugs.com/drug-class/antiseptic-and-germicides.html

https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html

https://www.cdc.gov/healthywater/emergency/hygiene-handwashing-diapering/index.html

https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf

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All Employees Must:

Alert the OSHA Safety Officer to any unsafe conditions or hazards

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Supply Monitoring

• We learned that during a pandemic people are hoarding and making it difficult to get essential supplies

• Not just medical supplies, paper items

• Do you know what you need to keep the doors of the practice open?

Complete OSHA form 300

If you experience any work-related illness or injury requiring medical treatment report it to your OSHA Health and Safety Manager as soon as possible.

1/18/2021

Article: How ODs Are Addressing COVID-19• Canceling all non-urgent optometry appointments to limit staffing and patients in the medical centers.• Doctors are working a rotating 12-hour schedule to allow other doctors to stay home and to reduces people in the centers.• Technician support has likewise been reduced on rotation and overall hours.• No contact ocular testing unless absolutely necessary that day; this includes gonioscooy, tonometer, and contact pachymetry.• No non-contact tonometry (NCT), especially for patients with red eyes.• Patients are asked at the front desk to wash hands or apply hand sanitizer before they enter any examination area.• Staff wipes down spectacles of presenting patients.• All slit lamps feature homemade sneeze guards, letter-size.• All exams are problem focused, so no ancillary testing will be performed unless needed for diagnosis or change in treatment.

https://www.optometrytimes.com/coronavirus/how-ods-are-addressing-covid-19-their-practices

Continue…

• Full exam chair and instrument wipe down with disinfectant wipes (not tiny alcohol preps) between each patient.• Any patient at risk will be given a face mask to wear.• Triage stations are located at security as patients enter the facility before they get to optometry. Triage stations are plastic rooms that were build to isolate at risk patients from passing security.• All clerical staff are reduced to alternating teams to report to work.• Clinical areas are compressed to reduce travel and staffing throughout facilities.• Maintenance are full schedule.• Some specialty services are cancelled.• Optometrists are selecting which patients must come in.• All directors appointed three people who could take over if they needed to be out.

Ordering COVID-19 Tests (local requirements) What is COVID-19? COVID-19 is the name for the respiratory syndrome caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

What is the test name and test code? The test name in the Test Directory is SARS-CoV-2 RNA, Qualitative Real-Time RT-PCR and the test code is 39433.

What is Quest’s test for COVID-19? The SARS-CoV-2 RNA, Qualitative Real-Time RT-PCR test is a qualitative molecular assay, which amplifies the RNA of the

SARS-CoV-2 virus in human specimens such as nasopharyngeal or throat swabs (upper respiratory). Alternative specimens,

including bronchial lavage/wash, nasopharyngeal aspirate/wash, or sputum/tracheal aspirate are also acceptable. The

technique is a real-time reverse transcription PCR assay.

How do I order the SARS-CoV-2 RNA, Qualitative Real-Time RT-PCR test?

Physicians may order the test using test code 39433.

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Resources

• Some slides have the information on them

• WHO• Coronavirus portal

• Situation dashboard

• CDC• Coronavirus disease 2019 (COVID-19)

• General information for health care professionals

• Evaluating and reporting persons under investigation

• Resources for hospitals and health care professionals preparing for patients with suspected or confirmed COVID-19

Relevant Articles

• EyeNet Extra: COVID-19 and Ophthalmology• Stepping up infection control measures in ophthalmology during the novel coronavirus

outbreak: an experience from Hong Kong• Priorities for the US Health Community Responding to COVID-19• Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe

Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient• Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS‐CoV‐2

infection• The Coronavirus Disease 2019 (COVID-19) Outbreak in China—Summary of a China

CDC Report• First Case of 2019 Novel Coronavirus in the United States• Clinical Characteristics of Coronavirus Disease 2019 in China• A Novel Coronavirus from Patients with Pneumonia in China, 2019

• Early epidemiological analysis of the coronavirus disease 2019 outbreak based on crowdsourced data: a population-level observational study

Respirator Information

• Information about Respirators:• A respirator is a personal protective device that is worn on the face, covers

at least the nose and mouth, and is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by the CDC/NIOSH, including those intended for use in healthcare.

• Respirator use must be in the context of a complete respiratory protection program in accordance with OSHA Respiratory Protection standard (29 CFR 1910.134external icon). HCP should be medically cleared and fit-tested if using respirators with tight-fitting facepieces (e.g., a NIOSH-approved N95 respirator) and trained in the proper use of respirators, safe removal and disposal, and medical contraindications to respirator use.

• NIOSH information about respirators

Industry feedback

• If you have practical, clinical experience to share about the COVID-19 outbreak, please send to onefeedback@aao.org. The site editors will review and post items that will benefit the community. • Photo Credit: Content Providers(s): National Institute of Allergy and Infectious

Diseases (NIAID) - This media comes from the Centers for Disease Control and

Prevention's Public Health Image Library (PHIL), with identification number #18109.